Utilization Review Registered Nurse
2 weeks ago
At Cooper University Health Care, we prioritize exceptional health care through our dedicated team. Our skilled professionals are at the forefront of clinical advancements, ensuring access to the latest facilities, equipment, technologies, and research methodologies. We are committed to our employees by offering competitive compensation, comprehensive benefits, favorable working conditions, and opportunities for career growth through professional development.
Discover why Cooper University Health Care stands out as the employer of choice in South Jersey.
Short DescriptionThe Utilization Review Registered Nurse employs payer-specific assessment tools to aid in evaluating the level of service and medical necessity. This role involves conducting utilization reviews in compliance with all state regulations.
Engagement with the Physician Advisor is essential to discuss matters of medical necessity, length of stay, and care appropriateness.
Proactively identify and manage concurrent and retroactive denials through effective communication with attending physicians, case management, multidisciplinary teams, external physician resources, and payers. Document the review and denial processes within the EPIC Case Management Module.
Respond to payer requests for necessary information and treatment plans. Review and confirm physician orders, reporting progress and any unusual occurrences related to patients to the payer.
Experience RequiredA minimum of 5 years of recent clinical experience, ideally within a specialized population area.
Experience in utilization management or review is preferred.
Strong knowledge of disease protocols and clinical pathways for both commercial and government payors is essential. Familiarity with Interqual and Milliman guidelines, as well as regulatory mandates, is advantageous.
Excellent communication skills (both written and verbal) and critical thinking abilities are required. Professional presentation skills are also necessary.
Education RequirementsA Bachelor's degree in Nursing is preferred.
License/Certification RequirementsA current NJ-RN License is required.
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